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Nurse practitioners are one of only two professions that can provide medical assistance in dying. But in Ontario, they can't prescribe controlled substances and drugs.Photographee.eu/ Photographee.eu - Fotolia

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Nurse practitioners across the province are getting dozens of requests for medical assistance in dying, but their hands are tied about providing it, says the head of the association that represents 2,200 of these advanced care nurses in Ontario.

Under federal legislation passed in June, physicians and nurse practitioners are the only professions permitted to provide medical assistance in dying (MAID) to competent and consenting adults who have an irremediable condition and face a foreseeable death.

Nurse practitioners can assess patients to determine if they qualify for MAID. However, Ontario is the only jurisdiction in North America that doesn’t allow nurse practitioners to prescribe controlled drugs and substances, including the drugs used to hasten death, meaning they can’t provide MAID.

“We’re getting dozens of calls saying, ‘This patient knows me. They trust me. They want me to explain the implications. They want me to be the person in the room,'” said Theresa Agnew, chief executive of the Nurse Practitioners’ Association of Ontario. “We can’t prescribe the sedatives and barbiturates needed.”

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In one case, a longtime patient asked a nurse practitioner for MAID, but the request had to be referred to another provider, said Agnew.

“The patient said, ‘I want you to be by my side.’ It’s one example where the current policy impedes access to continuing care,” she said. “It’s confusing for people. They know nurse practitioners were named in the federal bill. We’re starting to get a lot of questions.”

Roberta Heale, president of the Canadian Association of Advanced Practice Nurses, said the association does not have Canada-wide numbers on requests for MAID made to nurse practitioners. There is also no database of nurse practitioners who provide MAID.

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Nurse practitioners have worked in Ontario since the 1970s. They are registered nurses with additional university education that qualifies them for an extended scope of practice. They are registered with the College of Nurses of Ontario in specialties, including primary care, adult care, pediatric care and anesthesia. They are involved in the care of four million patients in Ontario, said Agnew. Many nurse practitioners work in primary care in rural and underserved areas, where access to MAID is limited.

About 400 of the Ontario association’s members responded to an online survey about MAID last spring, shortly before the legislation was passed. The respondents included nurse practitioners from all parts of the province. About 85 per cent worked in primary health care. About six per cent — for example, those who work in sexual health — said MAID would not be applicable to their practice. About 16 per cent said they would not provide MAID. About 78 per cent said they would provide MAID if they had the knowledge, skill and judgment.

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While the association says nurse practitioners can abide by their consciences and their moral and ethical beliefs when it comes to MAID, it also expects that members who refuse to provide MAID refer patient to another practitioner in a timely manner.

“We respect our members’ ethical perspectives and their beliefs. But we also respect the patient’s autonomy and wishes,” said Agnew. “You can’t close the door on a patient’s request.”

In 2012, federal regulations were amended to permit nurse practitioners to prescribe controlled substances. Both Premier Kathleen Wynne and Minister of Health Eric Hoskins have said Ontario plans to expand the scope of practice for nurse practitioners.

Agnew expects it will happen by March 2017. Until then, the inability to prescribe goes beyond MAID and affects the day-to day assistance nurse practitioners can offer in other areas as well, including palliative care, pain management, and post-operative care.

“We have more than 100 nurse practitioners who provide palliative care in the community. They also can’t prescribe these medications. And a physician can’t delegate the prescribing authority,” said Agnew.

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